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It was a “major failing” for Joel Cauchi’s former psychiatrist not to recognise he had relapsed in the lead up to the Bondi Junction stabbings in 2024, a coroner has found.
The state coroner, Teresa O’Sullivan, handed down her findings in an 837-page report on Thursday after she had delayed its release following the Bondi beach terror attack in December.
She recommended changes to the New South Wales mental health system.
Family members of the victims gathered in court to hear the coroner’s findings regarding 40-year-old Joel Cauchi’s violent attack at a Westfield shopping centre.
Cauchi, who lived with schizophrenia, killed Ashley Good, 38, Jade Young, 47, Yixuan Cheng, 27, Pikria Darchia, 55, Dawn Singleton, 25, and Faraz Tahir, 30, and injured 10 others before he was shot and killed by police Insp Amy Scott.
O’Sullivan determined that all six people died of stab wounds.
“While this inquest cannot ever change what happened, it is hoped the recommendations can provide an opportunity for reform which could save future lives,” O’Sullivan said on Thursday.
O’Sullivan said she would be referring Cauchi’s former psychiatrist, Andrea Boros-Lavack, to the Queensland ombudsman to examine her care of him.
But O’Sullivan said it was “important to note” that her care was not a major factor that led Cauchi to murder six people. Senior counsel assisting the inquest, Dr Peggy Dwyer SC, said late last year that “no one could have foreseen the tragic events of 13 April [2024] – it’s not suggested that Dr Boros-Lavack could have”.
The coroner said on Thursday that Boros-Lavack’s care of Cauchi from 2012 to 2019 was exemplary and compassionate, and she did the right thing in listening to his wishes to wean off his medication.
However, O’Sullivan found that Lavack “failed” to assess the seriousness of “what was unfolding before her” when he relapsed.
“The care that was provided was one of the many factors that led to this tragic outcome,” she said.
“While this inquest cannot ever change what happened, it is hoped the recommendations can provide an opportunity for reform which could save future lives.”
She said the inquest was both an opportunity to examine Cauchi’s care, but also the systemic issues in the state’s mental health system.
She recommended the NSW government establish and support short- and long-term accommodation for people experiencing mental health issues and homelessness.
The coroner recommended the NSW government, over the next 12 months, obtain advice about the decline of mental health outreach services and determine a “realistic timeline” to resource such services.
The tragedy was the ‘end point of a long story’
Outside the court, families of three of the victims spoke to reports. Jade Young’s hudband, Noel McLaughlin, said: “Jade was my wife, the person I shared life with for more than two decades, her absence has left a vast and permanent space, one that can’t be filled only carried.”
“While the inquest can’t undo our loss, it has mattered. It has helped us understand what happened, and it has examined these events with seriousness, care and dignity.
“The evidence has shown that what first appeared to be a sudden and random act of violence was, in fact, the end point of a long story.”
The father of Ashley Goode also spoke briefly. He said: “if the shopping centre systems were correct, the staff that worked there in the positions that they were in that day, they had done their job successfully. My daughter would still be alive today.”
Three members of Faraz Tahir, the security guard who lost his life and was on the first day of the job, also spoke. They recalled his bravery.
A major concern raised within the inquest was whether earlier activation of the shopping malls security alerts could have saved lives, particularly the last of Cauchi’s victims. O’Sullivallian found it wasn’t a “realistic possibility” that it would have given the time it took for Cauchi to complete his fatal attacks.
Cauchi was in a psychotic state and armed with a 30cm hunting knife when he went to the Westfield shopping centre. In just after three minutes, Cauchi moved through three levels of the centre, stabbing 16 people.
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O’Sullivan found that the policies of the mall’s security firm, Scentre Group, to deal with an active armed offender event “can only be described as excellent”, despite failures to enact some of those on the day.
She said that one of the CCTV control room operators, known as CR1 due to a suppression order over her identity, was not competent and should not have been left unsupervised. She said the finding is not a personal criticism, but a management one.
“[It was] a deliberate managerial decision to by Scentre Group and Gladd Group who would have been aware she did not have the skills necessary,” O’Sullivan said.
O’Sullivan found issues with how the NSW police and ambulance service worked together and communicated when responding to the attack. She highlighted in her summary a recommendation for the state’s emergency services to convene and develop a framework that deals with this issue and draws on the evidence from the inquest.
Among her highlighted recommendations was for the NSW government to roll-out campaign that educates the public on what the active offender messaging of “escape, hide, tell”.
The inquest spent many days examining Cauchi’s interactions with police and mental health services in the lead up to the attack. He had had several interactions with Queensland police from 2021 to 2023 with police.
The most prominent interaction was a year before the tragedy at Bondi, when officers responded to a report he had made that his dad had stolen his knives. During that visit to his parents home in Towoomba, where he was living in at the time, his mother had told police: “I don’t know how we’re going to get him treatment unless he does something drastic.”
The officers then sent an email to the officer in charge of mental health referrals in the area command, but he missed it. In her findings, O’Sullivan did not criticise the officer for missing the email, saying he had a “significant workload”.
She said the Queensland police force had now enacted changes so that such referrals are always actioned.
Sue Chrysanthou SC, who acted on behalf of some of the victims families, told media outside the court that the families may have more to say in the coming days after they have had time to examine the report.
McLaughlan said told reproters: “It’s revealed gaps, missed opportunities, systemic failures across mental health, policing and the way crowded places are kept safe. I want to acknowledge the courage of the first responders and members of the public who acted that day.”
“My hope now is that the findings and the recommendations are treated not as abstract lessons, but as practical obligations.”
